MedicalRiskAssessmentoftheDentalPatient:

“Don’tTreataStranger”

October2019

SophiaSaeed,DMDProfessorinResidenceandChairDepartmentofClinicalSciences

SchoolofDentistryUniversityofNevada,LasVegas

LearningObjectives

• Assessapatient’smedicalriskandsuitabilityforelectivedentalcare.

• Discussthemainmedicalconditionsandmedicationsthatimpacttheriskofbleeding,woundhealing,andinfection.

• Determineifmodificationsarenecessarytodentaltreatmentormanagementbasedonthepatient’smedicalstatus.

Resources

• UpToDateà “ScholarlyWikipedia”• Little,JamesW.DentalManagementoftheMedicallyCompromisedPatient,7thEdition.Mosby,2008.VitalBookfile.

• ADAEBD:https://ebd.ada.org/en• JournaloftheAmericanDentalAssociation• RealBodiesexhibit- areviewofanatomy

Guidelines

• Evidence-basedguidelinesareamovingtarget• Sciencechanges• Qualityofarticles???

Assessapatient’smedicalriskandsuitabilityforelectivedentalcare.

WhatisRiskAssessment?

WhatisMedicalRiskAssessment?

AmericanSocietyofAnesthesiologists(ASA)Status

ClevelandClinicwebsite

CariesRiskAssessment

Caries&WhiteSpots

OralHygiene

Fluoride&Xylitol

Diet

SalivaryFlow

Low Moderate High Extreme

MedicalRisk

Assessment

Current/PastConditions+stability

Meds+pastrelevantmeds+compliance

SurgicalHx/Hospitalizations

Allergies

Vitals

Safetoproceed,nomodifications

needed

Safetoproceed,modifications

needed

Proceedwithcaution,urgent

careonlyDefertreatment

Consequences

• Stroke– recentCVA/TIA,elevatedsymptomaticBP

• HeartAttack– elevatedsymptomaticBP

• Aspiration/Pneumonia• Systemicbacteremia/infection(brain,heart,etc.)• Bleeding• Bonyhealing

ModificationstoMgmt orTreatment

• Pre-procedureorprophylacticantibiotics• LAtypesoramount?• Shortappointments?• Stressreductionprotocol• Choiceofdentalmaterials• NoNSAIDsornarcoticsoracetaminophen• RBAoftreatmentoptions(e.g.exts,removableprosth)

• Treatmentsetting- needforphysiologicmonitors?

MedicalHistory

• Visualobservationofpatient• Vitals(mostlyBP)• LastMDvisit• Currentandpastmedicalconditions• Howwell-controlledareconditions

https://www.ahcusaweb.com/ProviderWeb/downloadfs.aspx?category=8&title=3%20&fromsite=1

• Howtomeasureabloodpressureaccurately:https://www.youtube.com/watch?v=gUHALsLeeoM

• ReviewofBPPhysiology:https://youtu.be/diG519dFVNs

MiniMedHx/ROSCardiovascular+Cerebrovascular

Check vitals.Difficultylyingbackward?Abletowalkupaflightofstairs?Angina- cause,carryNTG,howoftenneeded?Sleepw/howmanypillows?MI?CVA?When?Onbloodthinners?

Lungs Difficultylyingbackward?Sleepw/howmanypillows?Abletowalkupaflightofstairs?Hx ofpulmonary embolism?SupplementalO2?ActiveTB?

Kidneys Severelackoffunctionrequiringadjustment ofmeddosing?

Liver ActiveHep?Cirrhosis? Alcoholicliverdisease?Severelackoffunctionrequiringadjustment ofmeddosing?Bleeding?

Diabetes HbA1c?Dailybloodsugarrange?Polyuria, polydypsia?Tingling/neuropathyoffingersandtoes?Visionchanges?LasttimeMDchangedmeds/dosages?

Bone Bisphosphonateuse?Healingpotential 2/2immunecompromise?

Bleeding Too muchfromanti-coagulants?Lowplatelets?Needlabvalues?Hemophilia?vWD?Toothick- stasisandincreasedriskofembolism?

Cancer RadiationTherapy- field,dose,type?Chemotherapy?IVbisphosphonatesinCT(breast&prostatecancer)?Immunestatus?

ImmuneSystem HIV+,s/porganorbone marrowtransplant,cancer,high-dosecorticosteroids,autoimmuneconditions- riskofsystemicinfection

Neurological Coherenceandcomprehension: abilitytounderstand RBA/giveconsent?Movementdisorders?

SurgicalHistory&Hospitalizations

• Pastorplannedsurgeryofmajororgans?• Removalofanymajororgans?• Replacement/transplantofanyorgansorjoints?• Complicationswithsurgeries?• Complicationswithanesthetics?• Overnighthospitalizations?

Medications

• CurrentMeds+Compliance• Psychmeds– “Iseeyouaretaking…..Whatareyoutakingthatfor?”

• PastandPlanned– bisphosphonates- route,lengthoftx,lastuse– RadiationTherapy(RT)- dose,field,typeChemotherapy(CT)- when?IncludingIVbisphos (espbreastandprostatecancer)?

Allergies/AdverseReactions

• Drug/classà reaction• Latexà reaction

PCNà anaphylaxisCodeineà constipationLatexà rash

Social+DentalHistory

• Job/Occupation/Howonespendshis/herdays• Tob/EtOH/Drugs• Behavior• Fear,anxiety,phobias• Previousbaddentalexperiences• Health-relatedbehaviors:oralhygiene,frequencyofaccessingcare,nutrition/diet,compliancewithMDrecommendations/meds

Hypotheticalvs.RealConcerns

Medical>Dental:Safety

• Acuteriskoflife-threateningmedicalevent(e.g.acutelyhighBP)

• Riskofbleedingorinfection>benefitoftreatmentbeingconsidered

• RiskofONJ/MRONJ>benefitofprocedure

• Emergent,Urgent,Elective…

MedicalRisk

Assessment

Current/PastConditions+stability

Meds+pastrelevantmeds+compliance

SurgicalHx/Hospitalizations

Allergies

Vitals

Safetoproceed,nomodifications

needed

Safetoproceed,modifications

needed

Proceedwithcaution,urgent

careonlyDefertreatment

ConferringwithMDs

ConferringwithMDs

ComplexPatient

Consultation

Getmoreinformation

AskspecificQs

Referral Referformedicalcare

“Wecannotabdicateresponsibilityfortreatmentdecisionstophysiciansandstillmaintainthestatusandprivilegeofaprimarycaregiver.”

• “MedicalClearance”fordentalprocedures– OUTDATED– Dotheyknowthesetting?– Dotheyknowtheprocedures?– Doesthisdoanythingforyou,medicolegally?– Doesithelpyouprovidesafercare?

GoodConsults

• Specificinformationaboutpatient• Specificquestionsin“yes/no”formatasoftenaspossible• Specificlabvaluesortestresults• Clarification/opinionintheabsenceofguidelines• Goal:AskONCE,gettheinfoyouneed,makedecision:– Tx w/nomods,tx w/mods,ER(urgent)careonly,toocomplex(risk>benefit)

ExampleMedConsultDearDr.______________,

Iamrequestinginformationregardingourmutualpatient__________(DOB__/___/__)sothatImaysafelyprovidehimdentalcare.Pleasecompletetheformbelowandreturnatyourearliestconvenience.

1. Whatisthestartdateofthepatient’suseofalendronate?_______________2. Hasthepatienttakenanyadditionaloralbisphosphonates?Yes/No3. Ifyes,pleaseprovidethestartdate_________and enddate__________.

Thankyousomuchforyouradditionalattentiontothispatient’scare.

_____________________________(MDsignature)

Sincerely,OralHealthProvider

Consult• More/clarificationofinformation- historyorlabvalues– Currentmeds– Pasthistoryoforalbisphosphonates– PasthistoryofIVbisphosphonates– PasthistoryofH&Nradiationtherapy(RT)– Poorhistorian– HbA1c,INR,CD4,neutrophils…– Previousinfectioninreplacedjoint

• Unclear/noguidelines– s/pOrgantransplant,dialysis,poorlycontrolleddiabetes

Discussthemainmedicalconditionsandmedicationsthatimpacttheriskofbleeding,woundhealing,andinfection.

Determineifmodificationsarenecessarytodentaltreatmentormanagementbasedonthepatient’smedicalstatus.

Bleeding

http://ib.bioninja.com.au/standard-level/topic-6-human-physiology/63-defence-against-infectio/clotting.html

AtRiskforBleeding

• VonWillebrand Disease• Hemophilias• Anticoagulated– Directoralanticoagulants(rivaroxaban,apixaban,dabigatran,edoxaban)

– VitaminKantagonists(INRforwarfarin/coumadin)– Lowmolecularweightheparins (preferredduringpregnancy)

• Lowplatelets

TreatmentinthedentalpracticeofthepatientreceivinganticoagulationtherapyKaplovitch,Ericetal.TheJournaloftheAmericanDentalAssociation,Volume150,Issue7,602- 608

TreatmentinthedentalpracticeofthepatientreceivinganticoagulationtherapyKaplovitch,Ericetal.TheJournaloftheAmericanDentalAssociation,Volume150,Issue7,602- 608

Infection

AtRiskforInfection

• Immunocompromised• Post-transplant(?)• Autoimmuneconditions(?)• ProstheticJoint(?)• Cardiac- AHAguidelines• Dialysis(?)

ProstheticJointInfections(PJIs)

SollecitoTP,etal.Theuseofprophylacticantibioticspriortodentalproceduresinpatientswithprostheticjoints.JADA,146(1).January2015.

AmericanHeartAssociation

WilsonW,etal.Preventionofinfectiveendocarditis:GuidelinesfromtheAmericanHeartAssociation.JADA,138.June2007.

WoundHealing

AtRiskforPoorWoundHealing

• Bisphosphonates/anti-resorptives• Head&Neckradiationtherapy(RT)• PoorlycontrolledDM• Immunocompromised• Obesity• PoorOH

Brand Name Generic Name Route Approved

Actonel residronate sodium oral 1998Atelvia residronate sodium oral 2010Bonefos clodronate disodium (not US) oral 1985/1992Boniva ibandronate sodium oral 2003Bonviva etidronate disodium oral 2004Didronel etidronate oral 1983

etidronate (g) alendronate sodium oral 2003Fosamax alendronate sodium oral 1995

Fosamax Plus D alendronate sodium/cholecalciferol oral 2005alendronate (g) alendronate sodium oral 2008

Skelid tiludronate disodium oral 1997Aredia pamidronate disodium IV 2001Bonefos clodronate disodium IV 1985/1992

Boniva IV ibandronate sodium IV 2006Reclast zolendroic acid IV 2005/2007Zometa zolendroic acid IV 2001

AdaptedfromHellsteinJW,etal.JADA2011.

Who Rx’s? Diagnosis Route Potency

Primary MDsOsteoporosis,

Osteopenia, Paget’s disease of bone

Oral, Injection Low

EndocrinologistsOsteoporosis,

Osteopenia, Paget’s disease of bone

Oral, Injection Low

Oncologists

Multiple Myeloma, hypercalcemia of

malignancy, treat and reduce risk of bone metastasis in breast

cancer

IV High

OralBisphosphonates-AAOMSPositionPaper

• New-ish drugclassintheUS

OralBisphosphonates-AAOMSPositionPaper

>4yearsoforalbisphosphonates?

2-monthdrugholidaybeforeinvasivedentalprocedure

WhataboutIVbisphosphonates?

M.A.Pogrel,DDS,MD

M.A.Pogrel,DDS,MD

Specifics

• Pacemakers• Riskofstoppingbloodthinners• COPDandO2• Pregnant• H&Ncancer• Drugs:methamphetaminesandcocaine

Pregnancy

OralHealthDuringPregnancyandEarlyChildhood:Evidence-BasedGuidelinesforHealthProfessionals.CDAJournal,Vol 38,No6.June2010.

RadiationTherapy

Traditional IMRT

OtherConsiderations

AbilitytoLieSupineandStill

• CongestiveHeartFailure- NYHAClassification• COPD• GERD• Seizures• RLS(restlesslegsyndrome)• Parkinson’s• Choreas

TreatmentSetting

• Nophysiologicmonitoring(likeEKGandcontinuousBPandO2inoperatingroom)

• Openversusclosedrooms• Availabilityofsedationoptions• Treatmenttakesmonths

OverallMedicalRisk- Framework1• Systemicallystable?• RiskforAcuteMedicalEvent?• Abletoliesupine(andstill)forlengthofappts?• Riskofbacteremia/infection?NeedforAbx?• Riskofbleeding?– Needforfactorprophylaxis?(hemophilia,vwD)– Needforalterationofanti-coagulants?(riskvs.benefit)– Lowplateletcounts

• Healingpotential• AnyreasontohaveanMDconsult?• Necessityoftreatment?• Timelinessoftreatment?

OverallMedicalRisk- Framework2• Anyreasonnottoproceedwith…

– COE/POE– Periodontaltherapyorcariescontrol– Extractions/surgicalprocedures

• Anyotherreasontodelaytreatmentuntilmedicallystable?• AnyreasontohaveanMDconsult?

– Clarificationofdx,meds,orlabvalues– Stabilityofmedicalconditions– Consultationinareasofgray

• Anyothermodificationstocare?– (abx,INR,avoidNSAIDs,shortappts,nitrous?,avoidexts?

sedation?stressreduction?localanesthetic?NTG?Albuterol?Avoidremovable?)

• Abilitytoliesupine?Timelinessoftreatment?

ModificationstoMgmt orTreatment• Pre-procedureorprophylacticantibiotics• LAtypesoramount?• Shortappointments?• Stressreductionprotocol• Choiceofdentalmaterials• NoNSAIDsornarcoticsoracetaminophen• RBAoftreatmentoptions(e.g.exts,removableprosth)

• Treatmentsetting- needforphysiologicmonitors?

“Thesecretofthecareofthepatientiscaringforthepatient.”- FrancisW.Peabody,MD;addressingHarvardMedicalSchoolstudentsin1927

Summary

• Informationneededtoassessapatient’smedicalriskandsuitabilityforelectivedentalcare

• Emergent,Urgent,andElectivedentalcare• Medicalattentionsupersedingdentalneeds• Frameworkforthinkingaboutmedicalrisk